MEDICARE: ERIN ELIZABETH GILLIS IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1780081190
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN ELIZABETH GILLIS IBCLC

Provider Business Mailing Address
First Line	:	4326 SE WOODSTOCK BLVD # 412
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6270
Country	:	US
Telephone Number	:	503-914-1143
Fax Number	:

Provider Business Practice Location Address
First Line	:	4326 SE WOODSTOCK BLVD # 412
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97206-6270
Country	:	US
Telephone Number	:	503-914-1143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2014
Last Update Date	:	12/01/2014

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